Leave this field blank How would you describe your daily activity level? Sedentary Low Active Active Very Active Are you over the age of 65? Yes No Do you have any food allergies? Yes No Which foods are you allergic to? Do you take any medications? Yes No List your medication(s) and why you're on them. First Name Last Name Mobile Phone Number Email Would you like to join our Newsletter? You're information is kept confidential and you can opt out at any time. Yes No Send *Average weight loss on the Optimal Weight 5 & 1 Plan® is 12 pounds. Clients are in weight loss, on average, for 12 weeks.